Annals of African Medicine
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Year : 2013  |  Volume : 12  |  Issue : 4  |  Page : 193-196  

Ectropion and entropion in sub-Saharan Africa: How do we differ?

1 Department of Surgery, Lagos State University Teaching Hospital, Lagos, Nigeria
2 Department of Eye, Huddersfield Royal Infirmary, Huddersfield, United Kingdom

Date of Web Publication4-Dec-2013

Correspondence Address:
Bolanle G Balogun
Ophthalmology Unit, Department of Surgery, Lagos State University Teaching Hospital/College of Medicine, 1-5 Oba Akinjobi Street, GRA Ikeja, Lagos, Nigeria

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1596-3519.122682

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Aims: To study the etiopathophysiology of ectropion and entropion in a sub-Saharan tertiary eye care center and examine how it differs from reports elsewhere.
Methods and Materials: This was a retrospective audit of all consecutive patients who presented with ectropion or entropion to the oculoplastics clinic of a tertiary eye care unit. We reviewed the medical records of all such patients and data extracted include age, gender, etiopathology, and diagnosis. The primary oculoplastic disease was used in classifying the patients. The study period covered January 2008-June 2012.
Results: A total of 53 patients were identified constituting 37.3% of all eyelid diseases. Thirty-three (62.3%) were males. Forty-eight (90.6%) had ectropion, 43(89.6%) of which were cicatricial ectropion. Five (9.4%) had entropion. The median age group affected was 30-39 years (26.4%). There were no cases of congenital ectropion or entropion. The leading etiological factor was trauma in 36 cases (67.9%), which was mostly due to road traffic accidents (50.9%).
Conclusions: This study highlights a difference in etiopathophysiology of ectropion and entropion in a sub-Saharan region when compared to reported data from developed countries. In Nigeria, ectropion (which is often cicatricial) is usually secondary to trauma whereas senile involution is the common cause in many developed countries. This finding has implications in appropriate planning and skill acquisition for surgical correction in this group of patients.

   Abstract in Spenish 

Objectifs :
Pour étudier l'etiopathophysiology de l'ectropion et entropion dans un centre de soins yeux tertiaire subsaharienne et examiner comment elle diffère des rapports ailleurs.
Méthodes et matériels: Ce fut une vérification rétrospective de tous les patients consécutifs qui a présenté avec l'ectropion ou entropion à la clinique de l'oculoplastie d'une unité de soins oculaires tertiaire. Nous avons examiné les dossiers médicaux de tous ces patients et les données extraites incluent l'âge, le sexe, etiopathology et diagnostic. La maladie primaire oculoplastique a été utilisée pour classer les patients. L'étude a couvert 2008-June de janvier 2012.
Résultats : Un total de 53 patients ont été identifiés constituant 37,3 % de toutes les maladies de la paupière. Trente-trois (62,3 %) étaient des hommes. Quarante-huit (90,6 %) avaient un ectropion, 43(89.6%) dont étaient ectropion cicatricielle. Cinq (9,4 %) avait l'entropion. Le groupe d'âge médian touché était 30-39 ans (26,4 %). Il n'y a aucun cas de congénital ectropion ou entropion. Le facteur étiologique principal était un traumatisme dans 36 cas (67,9 %), qui était principalement due à des accidents de la route (50,9 %).
Conclusions : Cette étude met en évidence une différence dans l'etiopathophysiology de l'ectropion et entropion dans une région subsaharienne par rapport aux données recueillies entre les pays développés. Au Nigeria, ectropion (qui est souvent cicatricielle) est habituellement secondaire à un traumatisme, tandis que l'involution sénile est la cause fréquente dans de nombreux pays développés. Cette découverte a des implications dans l'acquisition de planification et de la compétence appropriée pour correction chirurgicale dans ce groupe de patients.
Mots-clés: Ectropion, entropion, Afrique subsaharienne, traumatisme

Keywords: Ectropion, entropion, sub-Saharan Africa, trauma

How to cite this article:
Balogun BG, Adekoya BJ, Balogun MM, Ngwu RV, Oworu O. Ectropion and entropion in sub-Saharan Africa: How do we differ?. Ann Afr Med 2013;12:193-6

How to cite this URL:
Balogun BG, Adekoya BJ, Balogun MM, Ngwu RV, Oworu O. Ectropion and entropion in sub-Saharan Africa: How do we differ?. Ann Afr Med [serial online] 2013 [cited 2022 Dec 7];12:193-6. Available from:

   Introduction Top

Ectropion is the outward turning of the lid margin. Entropion on the other hand, depicts inward turning of the lid margin causing the eyelashes to rub on the cornea. Both eyelid conditions can potentially impact ocular surface integrity. Al-Yousuf [1] noted that 5% of his study population had abnormal lid position as risk factor for microbial keratitis. Ectropion and entropion are predominantly the disease of the elderly, [2],[3] and there is histopathological evidence to support this. [4],[5] In the developing countries of Africa, Asia, and Latin America, cicatricial entropion and its blinding sequelae occurred mainly in trachoma endemic regions. Nasr reported cicatricial entropion as the commonest complication in his study. [6] We, however, suspect, based on our clinical experience that these findings may be different in our environment. This paper, therefore, aims to study the etiopathological pattern of ectropion and entropion in Nigeria and thus find out if indeed our findings differ from other reports.

   Materials and Methods Top

This is a retrospective descriptive study carried out on all consecutive patients presenting at the oculoplastic unit of a tertiary eye care center between January 2008 and June 2012. All cases with diagnosis of ectropion and entropion during the study period were included. Data extracted from the medical records include age, gender, disease etiology, and diagnosis. The approval to carry out this study was obtained from the Institutional ethical committee.

   Results Top

Fifty-three patients were identified during the study period of which 33 (62.3%) were males. The lower lid was involved in 30 (56.6%) cases and the upper lid in 20 (37.7%) cases. Only three (5.7%) patients presented with involvement of both upper and lower lids. Most patients presented between the third and fifth decades of life, with a peak at 30-39 years (26.4%) [Figure 1]. Forty-eight (90.6%) presented with ectropion while five (9.4%) had entropion. Forty-three (89.6%) of those with ectropion were of the cicatricial type.
Figure 1: Age distribution of the patients

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There was a male preponderance for ectropion and a female preponderance for entropion [Figure 2]. Trauma 36 (67.9%) was a major cause of all eyelid abnormalities (entropion and ectropion) [Table 1]. The predominant pathology was cicatricial ectropion in 43 constituting 81.0% of all cases [Figure 3]. There were no recorded cases of either congenital ectropion or congenital entropion.
Figure 2: Disease distribution among patients by gender

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Figure 3: Pattern of disease distribution among the patients

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Table 1: Etiopathological distribution among the patients

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   Discussion Top

Ectropion and entropion are characterized by malposition of the eyelid. Both conditions result in chronic irritation of the eyes, redness, watering, and loss of the protective functions of the eyelid. In addition to these, ectropion is often associated with conjunctival keratinization and globe exposure. The in-turned eyelashes in entropion can potentially cause progressive corneal damage and complications such as corneal ulcers and permanent scarring. Ectropion and entropion are therefore potentially vision-threatening. The ocular surface is dependent on the physiological and anatomical integrity of the eyelids and adnexal structures. [7] Al-Yousuf [1] in his report suggests that 5% of his study population had microbial keratitis due to ocular surface exposure. Histopathological reports reveal that involutional atrophic changes involving the medial and lateral canthal tendons, the inferior retractors and horizontal lower lid laxity play a major role in the development of ectropion. [4],[5] It is also believed that ectropion and entropion are more prevalent in the elderly and that the prevalence increases with advancing age. [2],[3] The finding in our study differs from report in the literature - the most prevalent type of ectropion was cicatricial ectropion presenting predominantly in the third to fifth decades, with a peak in the fourth decade of life. Only 5 (9.4%) presented with both involutional ectropion and involutional entropion. A possible explanation for this could be the fact that this is a hospital based study. Marshal et al., [8] found an association between involutional eyelid changes and actinic skin damage. Our study was carried out among the black population. The protection offered the black race by melanin against anterior lamella actinic changes may therefore also explain the very low prevalence of involutional changes in this study. Those who presented with cicatricial diseases had been exposed to accidental injuries mainly road traffic accidents 27 (50.9%). A few were due to physical assault or chemical burns. Motor bikes are frequently used as a form of transportation in the large urban commercial center where this study was carried out. This predisposes to a great chance of road traffic accidents causing facial and periorbital injuries which can eventually lead to cicatricial ectropion and entropion as complications. Chalya [9] recently reported that motorcycle injury is an emerging public health problem in Africa. The findings of our study is also similar to report from Nepal which found that eyelid trauma (37.2%) was the second commonest condition causing eyelid abnormality requiring oculoplastic surgery. [10] Trachoma endemic zones of Africa, Asia, Middle East, and parts of Latin America and Australia have recorded high prevalence of trachoma blindness [11] resulting from cicatricial entropion and trichiasis. [12] Our report, however, shows only two (3.6%) cases of cicatricial entropion were recorded. This may be explained by the fact that trachoma is not present in the southern region where this study was conducted.

   Study Limitations Top

This study has its limitations in that it was hospital based and it worked with a smaller population which may actually have been responsible for the higher number of cases of cicatricial diseases as opposed to comparative studies that examined large community-based population.

   Conclusions Top

Report from our study suggests that the etiopathophysiology of ectropion and entropion differ in our study population when compared to report from the western world particularly in terms of age at presentation and etiology. Patients in the third and fourth decades (the most economically productive period of life) and who tend to commute more frequently were more likely to be affected. Majority of the patients had cicatricial ectropion. Continuing efforts at minimizing trauma particularly from road traffic accidents need to be put in place. It is now mandatory for motorcyclists in Nigeria to wear crash helmet. It is also important that ophthalmologists and oculoplastic surgeons recognize the need for prompt and appropriate management of eyelid injuries. This, hopefully, will further reduce the burden of cicatrizing eyelid deformities as well as minimize unacceptable functional and cosmetic sequelae of such eyelid injury.

   Acknowledgments Top

We acknowledge the manuscript preparation work done by Ubani Anthony Balogun and the encouragement provided by Dr. E.D. Balogun.

   References Top

1.Al-Yousuf N. Microbial keratitis in Kingdom of Bahrain: Clinical and microbiology study. Middle East Afr J Ophthalmol 2009;16:3-7.  Back to cited text no. 1
2.Damasceno RW, Osaki MH, Dantas PE, Belfort R Jr. Involutional entropion and ectropion of the lower eyelid: Prevalence and associated risk factors in elderly population. Ophthal Plast Reconstr Surg 2001;27:317-20.  Back to cited text no. 2
3.Mitchell P, Hinchcliffe P, Wong JJ, Rotchchina E, Foran S. Prevalence and associations with ectropion in an older population: The Blue Mountains Eye Study. Clin Experiment Ophthalmol 2001;29:108-10.  Back to cited text no. 3
4.Stefanyszyn MA, Hidayat AA, Flanagan JC. The histopathology of involutional ectropion. Ophthalmology 1985;92:120-7.  Back to cited text no. 4
5.Bashour M, Harvey J. Causes of involutional ectropion and entropion--age-related tarsal changes are the key. Ophthal Plast Reconstr Surg 2000;16:131-41.  Back to cited text no. 5
6.Nasr AM. Eyelid complications in trachoma. I. Cicatricial entropion. Ophthalmic Surg 1989;20:800-7.  Back to cited text no. 6
7.Hintschich C. Correction of entropion and entropion. Dev Ophthalmol 2008;41:85-102.  Back to cited text no. 7
8.Marshall JA, Valenzuela AA, Strutton GM, Sullivan TJ. Anterior lamella actinic changes as a factor in involutional eyelid malposition. Ophthal Plast Reconstr Surg 2006;22:192-4.  Back to cited text no. 8
9.Chalya PL, Mabula JB, Ngayomela IH, Kanumba ES, Chandika AB, Giiti G, et al. Motorcycle injuries as an emerging public health problem in Mwanza City, Tanzania: A call for urgent intervention. Tanzan J Health Res 2012;12:4.  Back to cited text no. 9
10.Gautam P, Adhikari RK, Sharma BR. A profile of eye-lid conditions requiring reconstruction among the patients attending an oculoplasty clinic in Mid-Western region of Nepal. Nepal J Ophthalmol 2011;3:45-51.  Back to cited text no. 10
11.Landers J, Henderson T, Craig J. Prevalence and associations of blinding trachoma in indigenous Australians within central Australia: The Central Australian Ocular Health Study. Clin Experiment Ophthalmol 2010;38:398-404.  Back to cited text no. 11
12.Landers J, Kleinschmidt A, Wu J, Burt B, Ewald D, Henderson T. Prevalence of cicatricial trachoma in an indigenous population of Central Australia: The Central Australian Trachomatous Trichiasis Study (CATTS). Clin Experiment Ophthalmol 2005;33:142-6.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]

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